New Health Chinese Medicine Clinic Registration
This form will be used as both a registration form for those coming into our clinic and also a contact tracing form. Details collected in this form will be stored for 28 days for the purpose of contact tracing if required.
* Required
First Name
*
Your answer
Surname
*
Your answer
Email or Contact Number
*
Your answer
Date you are visiting the clinic
*
MM
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DD
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YYYY
COVID-19 Screening and Contact Tracing
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Please only tick if this applies to you. If you have any symptoms please alert staff. If you have been in contact with confirmed cases of COVID-19 or have been advised to self-isolate, we politely ask you to book telehealth and look forward to you visiting the clinic again. Thank you.
I have not tested positive for COVID-19, or come in contact with an confirmed cases in the past 14 days.
I have not travelled internationally, interstate, or to any known COVID-19 hotspots in the past 14 days
I understand that the information I have provided will be stored for the purpose of contact tracing.
Required
Outline any COVID-19 symptoms you may have if relevant
COVID-19 symtoms include fever, sore throat, cough, shortness of breath, loss of taste/smell). If doesn't apply please skip
Your answer
Thank you for taking your time filling in your details for COVID-19 screening and tracing.
On your arrival your temperature will be checked and please wear a mask, follow rules of physical distancing and adequate hand hygiene.
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